Vendor Payment Request Forms Important Points Payment cannot

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Vendor Payment Request Forms

Vendor Payment Request Forms

Important Points • Payment cannot be made until a correctly completed form AND invoice

Important Points • Payment cannot be made until a correctly completed form AND invoice or voided receipt are received in addition to having a matching approved authorization. • Must be submitted timely – Submit as soon as possible after the service has been provided but no later five months from the date of when the service was provided. • If a correctly completed form and invoice is not submitted timely, you may be responsible for payment • Cost and Service code on the form must match approved authorization EXACTLY • Only one vendor per form – you can have multiple requests on same form only if they are all to the same vendor

Filling out vendor form: First Section Jane Smith OK 1234 Julie Smith John Jackson

Filling out vendor form: First Section Jane Smith OK 1234 Julie Smith John Jackson • Service recipient Acumen ID # can be found on the Good to Go paperwork received after enrollment as well as through the web portal. If you still need help getting the ID number, please call us.

Filling out vendor form: Second Section Success Adult Learning Center 12 -3456789 123 Success

Filling out vendor form: Second Section Success Adult Learning Center 12 -3456789 123 Success Lane Success Adult Learning Center Success City, OK 12345 • If you are unsure of what to enter in the Vendor FEIN or SS# please contact the vendor • Please be aware the payment will be sent to the address on the vendor’s W-9 so if the vendor is a national organization, please include the client’s account number with that vendor to help direct payment

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Please note service end

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Please note service end date could be the same day as the start date if the service approved is approved on a daily basis Ex. Therapeutic horseback riding lesson – start and end dates would be the date the lesson occurred.

Finding Service Code

Finding Service Code

Finding Service Code

Finding Service Code

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Dec. 2020 Payment 473.

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Dec. 2020 Payment 473. 00

Finding Cost Important: This rate should exactly match the rate on the invoice you

Finding Cost Important: This rate should exactly match the rate on the invoice you submit If rate doesn’t match exactly, contact your case manager to complete an addendum

Finding Cost Important: This rate should exactly match the rate on the invoice you

Finding Cost Important: This rate should exactly match the rate on the invoice you submit If rate doesn’t match exactly, contact your case manager to complete an addendum

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Dec. 2020 Payment 473.

Filling out vendor form: Third Section 12/01/20 12/31/20 T 2025 Dec. 2020 Payment 473. 00 01/01/21 01/31/21 T 2025 Jan. 2021 Payment 473. 00 946. 00

Filling out vendor form: Fourth Section

Filling out vendor form: Fourth Section

Questions? If you have questions regarding how to complete the form, please contact us:

Questions? If you have questions regarding how to complete the form, please contact us: Oklahoma Office: 918 -221 -7053 Customer Service: 877 -364 -2835 Acumen. OK@Acumen 2. net

Things to remember • Payment cannot be made until a correctly completed form AND

Things to remember • Payment cannot be made until a correctly completed form AND invoice or voided receipt are received in addition to having a matching approved authorization. • Must be submitted timely – Submit as soon as possible after the service has been provided but no later five months from the date of when the service was provided. • If a correctly completed form and invoice is not submitted timely, you may be responsible for payment • Cost and Service code on the form must match approved authorization EXACTLY • Only one vendor per form – you can have multiple requests on same form only if they are all to the same vendor

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